63.11 Hemorrhagic RD

63.12 Additional Considerations

Only a few general comments are made here.

Q&A

QCan primary IOL implantation be performed in an eye with posterior segment injury?

AYes Ð if the risk of PVR is low (and the biometry could safely and reliably be done). Conversely, there is rarely a need to implant that urgently. Remember, the ciliary body and the posterior retina determine the visual outcome, not the presence (or absence) of the IOL (see below).

¥It is not only the vitrectomy that needs to be truly complete in trauma, but the ciliary body must also be thoroughly cleansed (see Sect. 32.5).

Ð One of the most commonly seen errors in VR surgery for a severely injured eye is the attempt to preserve the posterior capsule so that Òin-the-bag IOL implantationÓ will remain an option in the future.17

¥Silicone oil implantation, even if considered as prophylactic when no major VR pathology is seen at the time of the vitrectomy, should be the default option.18 Ð The oil should be kept in these eyes for longer than in most other indications

(see Sect. 35.4.6.1).

Quo Vadis, Medicina?

Sadly, many experienced VR surgeons abandon the Þeld of traumatology, leaving the management of these complex, difÞcult cases to the least experienced, often ill-trained, surgeon. It is obviously devastating for the patient who thus faces a worse prognosis. It is also terrible for the fellow, whose surgical efforts are doomed, even if this is not his fault. As mentioned in Chaps. 1 and 2, such failures have a doubly devastating impact: the fellow will not learn how to properly deal with injured eyes, and his conÞdence also suffers repeated blows.

17The same ideology is employed by the phacologist who in an eye with severe endophthalmitis argues against the removal of the capsule and the implanted IOL (see Part 2 in the Appendix).

18ÒDefaultÓ is deÞned as the choice unless strong arguments can be made against it.

¥Being able to successfully operate on complex trauma cases is a very rewarding experience, compensating for those cases where success has proved elusive.

¥At an institution where multiple VR surgeons work, a few should specialize in ocular traumatology and do most of the cases. If all surgeons do a few cases each, the outcomes will be suboptimal.

¥Among all subÞelds in VR surgery, traumatology is where the surgeon can be most innovative since very few absolute rules exist.

¥If the VR surgeon Ð or any ophthalmologist Ð is unable or unwilling to offer the proper treatment to the patient with an injury, the only acceptable option is to immediately refer the patient to a VR surgeon who is willing and able to do what is necessary (see Sect. 3.10).

ÐDelaying the referral is also unacceptable: it should be the VR surgeon who makes the decision regarding timing, not the referring ophthalmologist.